Provider Demographics
NPI:1831364108
Name:FULLER, JENNIFER RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:RENEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 LIVERNOIS ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2302
Mailing Address - Country:US
Mailing Address - Phone:313-864-9110
Mailing Address - Fax:313-864-8750
Practice Address - Street 1:334 LIVERNOIS ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2302
Practice Address - Country:US
Practice Address - Phone:313-864-9110
Practice Address - Fax:313-864-8750
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist